11:30 A.M. EST 
MODERATOR: Thank you, everyone, for joining us today. I'm going to just quickly introduce Dr. Tom Kenyon. He is our Principal Deputy Coordinator and Chief Medical Officer over at PEPFAR and he will talk a little about World AIDS Day, which I'm sure you know was this past Saturday, a little bit about PEPFAR as a program, and take any questions that you have about the program. So I'll turn it over to him.
DR. KENYON: Thank you. And just as a bit of background, I spent 15 years in Southern Africa, five in Swaziland and six in Botswana, and four in Namibia, but I never lived in Zimbabwe, and I didn't live in South Africa, but I worked a lot with your countries and with your colleagues.
I came here to D.C. in January of this year to support Ambassador Dybul in moving PEPFAR along. So I'll begin with some prepared remarks, but I do look forward to your questions, and that we are on the heels of World AIDS Day, but I think the theme of World AIDS Day is always there, isn't it?
So, you know, if we go back to the beginning of PEPFAR in 2003/2004, that was based on the growing recognition that, indeed, this had reached global crisis proportions, that emergency action was really necessary. And it was at that time that President Bush and our Congress, both parties, both House and Senate, decided to essentially do what we could to lead the world in restoring hope.
So PEPFAR is the single largest health initiative that any one government has taken on towards a single disease. So historically for us, and I think globally, it's a historical initiative.
On Saturday we commemorated World AIDS Day, which we always use as an opportunity to commemorate and remind ourselves of the more than 20 million people who have succumbed to HIV/AIDS since the beginning of this epidemic back in the early '80s. And just as importantly, to support the approximately 33 million people who are currently living with HIV. And we use this as an opportunity to recommit ourselves to compassionate action around the epidemic on the prevention, care, and treatment front, and also to begin to further explore how we can increase our partnerships. And we believe very much that these partnerships have immense power in them. It's not the United States alone in doing this at all. In fact, when we work in countries it really is a country-led, needs to be a country-led response. We come in with resources and expertise and a commitment to working together, but we really depend on the national leadership to move forward an effective response.
So on World AIDS Day the President announced our results to date, but again, these results are in partnership. PEPFAR doesn't accomplish these things alone. We do this together with the host countries, the host governments, the civil society in country, universities, and various other partners. But the President announced that in 15 of the most severely affected countries around the world -- those are our 15 focus countries that account for about half of the global epidemic -- that PEPFAR had supported antiretroviral treatment for more than 1.36 million men, women, and children. These are people with advanced AIDS who would otherwise die if they didn't receive this support. And again, done in partnership with the host country.
Globally, if we look beyond these 15 focus countries, that number was 1,445,500 people, so essentially nearly 1.5 million. But, you know, I think to put these achievements in perspective -- and, again, I was there during the '80s and '90s and the early part even of this decade when we really didn't have treatment -- and when we began PEPFAR, it's estimated we had around 50,000 people on treatment around Africa, in sub-Saharan Africa. So it's been a remarkable accomplishment, but again, we haven't done this by ourselves. This has been done through partnerships, and we also recognize that we still have a long, long way to go.
But the treatment aspect, which very much supports prevention and care, I think has been a major sign of hope and restoring hope that we're going to make a dent in addressing this epidemic and returning us to maintaining optimism. We're also seeing similar progress around prevention and care. Now prevention is a little more difficult to measure because we don't measure infections that don't happen; but we do measure, for example, the aspect of the epidemic of mother to child, which accounts for 10 to 15 percent, roughly -- in some countries higher -- of the overall epidemic.
So through September of this year, we had reached more than 10 million women with services to prevent mother-to-child transmission, beginning with counseling and testing so they can find out their HIV status. But again, we do this in partnership with the host country, with local non-governmental organizations, faith-based organizations who operate a lot of the health services in the countries, as we're all familiar with, community-based organizations that improve linkages between the community and the health sector, and the private sector, as well.
But in the course of reaching those 10 million women, we reached 800,000 women who were actually living with HIV and were pregnant and who received services to prevent mother-to-child transmission, usually in the form of medication, but also assistance with safer infant feeding, because that's also a mode of transmission. And we estimate -- these are from mathematical models but fairly well-established ones and based on science -- that we've averted some 152,000 newborn infants from acquiring HIV through the process of childbirth. So that's 152,000 children who would have otherwise become infected with HIV had we not had these partnerships and resources.
In terms of counseling and testing, we've now supported nearly 30 million individuals to learn their HIV status. Learning your HIV status is the gateway to care and treatment. It's also important in prevention, as well. And we supported care for nearly 6.7 million individuals, that's men, women, and children, but that includes care for more than 2.7 million orphans and vulnerable children, children who have been impacted by this epidemic and is one of the more tragic aspects of the overall crisis.
So again, we've been building capacity as PEPFAR has gone from year to year, and it's through these partnerships that we're building the capacity to provide services on this scale. But again, as the President said, it's the host nations who are the leader in this fight. We want to be led when we're working in a country. We don't come in with a preconceived notion that this is how we're going to respond to Zimbabwe's epidemic or South Africa's epidemic or what have you.
Yes, we have guidance. We have approaches, which I can talk about. They're based on scientific evidence, the best evidence that we have available, because we feel an obligation to guide the teams that we have on the ground who are working with your teams on the ground, that this is the latest evidence. This is what we think will work best.
Now, most of our partners are indigenous. Eighty-five percent of the organizations that we support through PEPFAR in your country are actually from that country. Yes, we do have U.S.-based partners, but we feel that to build a sustainable response, we have to engage indigenous partners, and we look to the country's leadership to guide us to who those partners should be and what would be their most effective -- efficient role in the local response.
Talking about prevention a bit, most HIV, at least in sub-Saharan Africa, is transmitted through sexual transmission, so -- and most HIV is in Southern Africa, or sub-Saharan Africa. Of the global estimate of 33 million, 22 million of those are estimated to be in sub-Saharan Africa.
So needless to say, most PEPFAR support goes to that part of the world. That's also part of the world where we're seeing some stabilization, but -- and there have been some improvements particularly in parts of central and east Africa, but in southern Africa we're seeing stabilization still at very, very high levels.
And stabilization isn't necessarily a good thing. If you have a lot of deaths and a lot of new infections, you've got stabilization, so we want to cut down both of those, new infections and the deaths.
So prevention remains the bedrock of what we're doing. We can't treat our way out of this epidemic. Treatment is, of course, important to save lives, but we have to be working simultaneously on the prevention front. And so we work with countries to develop the best evidence of what are the drivers around your epidemic. When we began PEPFAR in 2003/2004 we had some data, but we have much better information now. We work with global partners and host countries to do better surveys to get better evidence. That was one of the reasons why UNAIDS issued new projections. It was based on we think we have better data than we had when we made previous projections.
But through PEPFAR we're supporting the most comprehensive prevention approach of any development initiative worldwide. We're looking at all aspects of transmission.
So what are the drivers in your country? Is it sexual transmission? What aspects of sexual transmission. We also look at -- I've mentioned mother to child -- intravenous drug use, blood safety, make sure the blood supply is safe, make sure injections are safe, and so forth.
So we basically ask our teams, what caused the last thousand infections in your country? If you can answer that question, then you can guide and assess an effective response. If you're not able to really understand the current drivers, then a shotgun approach is not going to work. A broad approach that's not targeting the modes of transmission is not going to be effective. And I think that's some of what we've seen in parts of the world where the epidemic is not going down in terms of new infections, is that we haven't properly -- first of all, we didn't have the best data and we probably didn't -- where we did have data, we haven't yet applied the most effective programs.
So that's what we're trying to do on an on-going basis, and we urge our terms, if you have new information since last year's plan, you need to update your plan and redirect your resources to where prevention will make the greatest difference.
In terms of sexual transmission, we follow an approach that was innovated by African countries. I saw this the moment I got off the plane in the mid-'90s to serve in Botswana. And it's the so- called ABC approach that has somehow become very controversial, but where I was working and the colleagues with whom I worked in African governments and ministries of health, it wasn't controversial that this should be our approach, it was -- the controversy should be how do we go about doing this?
And essentially it's -- ABC, abstain, be faithful, and correct and consistent condom use. The idea behind abstinence is to empower young people, particularly young people, to wait until they're biologically ready, socially ready, to become sexually active. There are consequences of sexual activity that go beyond HIV. In fact, teenage pregnancy is a major challenge, especially to teenage girls, and interrupts their education and makes it difficult for them to progress later in life.
But also we see people who learn they're living with HIV to also make that choice. It's up to the individual to decide for them what is going to be their way of not acquiring HIV. The "be faithful" aspect, in particular, a huge driver of HIV, especially in southern Africa, is multiple concurrent partners. It's not sequential partners, it's having multiple partners over a specific time period, and I think that's very well accepted internationally. And I think this is probably the area that we have the most work to do, because there are a lot of drivers around that that are often beyond a woman's empowerment to make a decision. Women don't have a lot of say in decision making around sexual behavior in a lot of parts of the world, but particularly in sub-Saharan Africa.
And so we have to engage, the countries have to engage. Again, we, in the United States, we can be a catalyst. We can support that process. But it really requires a social and cultural transformation that we can't impose, obviously, as a partner. That has to come from the country, but we're very prepared to play our part.
And then, of course, correct and consistent use of condoms. A lot of misinformation that PEPFAR doesn't support condoms; nothing could be further from the truth. We're the leading supplier of condoms worldwide and support this fully. We estimate from January of '04 through November of this year, that globally we had procured more than 1.8 billion condoms to provide to partners in the countries where we work.
Now PEPFAR addresses HIV/AIDS, but we recognize there are many aspects of development that PEPFAR can both support and other aspects of development that are important to HIV/AIDS, such as education. Education is very important to empower individuals to eventually seek jobs and gain employment, and that's a factor in the epidemic.
We're also very much in need of a workforce who can support these initiatives on the scale that's required. We globally, we have a major health workforce crisis. The World Health Organization estimates we're more than 4 million health workers short of where we need to be globally. So we work with other initiatives, what we call connecting the dots of development, within our own government so that we can leverage the resources.
For example, we work a lot with the President's malaria initiative. We're working largely within a health system. Malaria is a major cause of mortality. There's some linkages between HIV and malaria, but mostly there's a lot we can do to use common supply chains, common training programs, information systems, and so forth. Obviously, the drugs differ, but we all need laboratories, for example. They're different tests, but when we're building infrastructure for one, we try to think of the other at the same time.
Similarly, with tuberculosis, which is a major killer of individuals both with HIV and those without HIV. We also work with the Millennium Challenge Corporation. In fact we've co-located with them in Lesotho, because there's a major MCC with Lesotho. Lesotho also has a major HIV epidemic. And with the Women's Justice and Empowerment Initiative; it's looking at gender-based violence issues and legislation and reinforcement of that legislation. And again, that affects sexual decision making.
And I've also alluded to education, but through the President we have the Africa Education Initiative. In particular, we link up with orphans and vulnerable children who need an education. We can support some of that, but we also need to leverage with other partners in government. And it's through these connecting the dots that support to Africa has been increased in a major way.
At the same time, though, we've doubled trade with Africa and we've provided 100 percent debt relief to the poorest countries, the ones most in need.
So our focus, you know, in the initial years -- we're now in the fourth year, moving into the fifth -- it was getting the resources out and emergency response, but now increasingly we're looking at building capacity so countries can sustain as much as this response as they can, recognizing that some countries have resources more so than others.
So we remain a partner with countries. We're not retreating. We have commitments to countries. We're keeping people alive. We're providing essential services that prevent a fatal infection. So there's no interest in retreating from that, but countries want to own this response. I think every country we work in, if they could flip a switch and we were gone and they're in full charge and have all the resources at their disposal, they would do that. But the reality is we're not there yet. So this is a long-term commitment. Again, we're in the third decade of this epidemic.
So looking to the future, I think we will continue to enjoy the strong support of the American people. They're seeing results from this initiative. Likewise, with Congress, of course, and I think we look at the first phase of PEPFAR as being the first quantum leap in support for global HIV/AIDS.
On World AIDS Day, the President repeated his call for Congress to reauthorize the emergency plan. As you may recall, he did this back in late May of this year, May 2007, and the call was for a five-year, $30 billion proposal that would be in addition to the initial $15 billion. So that's -- now we're still waiting for our 2008 appropriation, but we may have reached more than $18 billion in the first phase. With this 30 billion in the second phase, that would be $48 billion over a 10-year period. And having worked in this area since the mid-'80s, that's a quantum leap compared to what we were doing previously.
But then it didn't end there. The President went on to the G-8 that followed in June and came out of the meeting with a match by the rest of the G-8, so essentially a $60 billion commitment by the G-8 over a five year period to support HIV/AIDS, tuberculosis, and malaria programs. So this was really a landmark event, as well, and now for the very first time, we've had the other members of the G-8, the other leaders, join the United States in responding to this crisis.
So the targets overall for the entire G-8 is essentially doubling what PEPFAR is proposing that we would have done, so that would be to get -- we would have proposed with our own resources to support two and a half million people on treatment. If you double that that's five, so with the G-8 it would be 5 million on treatment. Likewise from the G-8 for prevention, preventing 12 million infections, and for care to support 12 million individuals, total 24 million for the G-8, including orphans and vulnerable children. So just to repeat those, for the G-8 it would be 5 million for treatment, 24 for prevention, and 24 for care.
So for -- of course we need to persevere in the meantime. We're not waiting to continue to work with countries to expand their response, but we're seeing successes and we're seeing successes because of partnerships, not because we're doing this alone and in isolation. And I think with maybe those opening remarks, I'll close there and open the floor to questions.
Thank you.
MODERATOR: If you could just briefly state your name and media organization.
QUESTION: Yeah, my name is Kwame Clement. I do a program called the African World for public TV stations. I might have missed it -- I mean, because the point about prevention being the key to this and I was wondering whether there is any focus on production of a vaccine.
DR. KENYON: That's a great question. I think, as I alluded to, for prevention of sexual transmission, we're pretty much dependent on behavioral change taking place, amidst other things that have to happen in society to enable that change to occur. And for certain, we're looking for so-called biomedical interventions that can support behavioral change.
The point I always make is that even with biomedical interventions, we'll still need to have behavioral change in place. We do have male circumcision, for example, that was thoroughly researched. A number of clinical trials that we supported, again in partnership, U.S. Government-supported partnership with countries, that showed essentially a 60 percent efficacy, a 60 percent level of protection, which is substantial. If we had a vaccine that worked that well, we'd be pretty pleased.
But we also need to be aware that that could create a false sense of security within society, in particular men, that would think, okay, everything's fine. I'm not going to be infected. There are -- oftentimes, at the societal level, there isn't this concept of partial protection; you know, I've got the shot, I must be good.
So going along with male circumcision, and we're working with a number of countries to try and roll that out when they want that as part of their prevention strategy, we need to ensure that there's a behavioral change communications component going out with that. So likewise, that would apply to any biomedical intervention that comes along and you rightly alluded to vaccines.
There were also -- this was a bad year for research. In addition to vaccines, we had a microbicide trial that didn't work, a female diaphragm trial that didn't work. But I think research has always encountered failures and disappointments. That's not new to research. It -- of course, we're disappointed by those results. There's a major communication piece that goes along, needs to go along with that to reassure people that we're researching the best interventions we think -- and the safest interventions -- we think we have at our disposal. But we don't know the ultimate answer to that question unless we carry out the trials, and there is a lot of scrutiny that's paid to these trials to ensure that people aren't harmed during the process of conducting them.
So in addition, no, vaccine research will continue. And something was learned from that vaccine trial. And there are a lot of challenges to vaccines. You know, the way vaccines work is they stimulate the immune system. Well, guess what? The way HIV replicates is through stimulation of the immune system. So there's an automatic frustration right there, biological obstacle -- and many others -- that the vaccine researchers are trying to overcome.
There are some promising microbicide trials. There is one under way in South Africa that Professor Salim Karim and his group are carrying out. We're actually funding that through PEPFAR, and we're hopeful that South Africa will give the world a tool. We're also looking at better female condoms, looking at -- there's some trials under way looking at medication to prevent transmission. Again, that could be a similar false sense of security, like male condoms -- sorry, like male circumcision. So, no, we're not going to give up on biomedical research, but in the meantime all we have for sexual transmission, primarily, is just the male and female condom, as well as behavioral change.
QUESTION: Thank you.
MODERATOR: Yes.
QUESTION: Thank you. Sonia Schott. Do you have anything on Latin America? Would you say that Latin America is facing the same problems as Africa? And the second one, very briefly, what would be the difference between developing countries and developed countries?
DR. KENYON: That's a great question. I think if you look worldwide, the epidemics are very, very different. Even if you look within countries they can vary. We can see a difference between drivers in an urban epidemic and a rural epidemic, in parts of the country that border other countries where certain things are at play.
So this is what I was getting at, you may have missed my initial comments, but we work with countries to gather as much information as possible about the drivers of the epidemic and the response should be based on that. The epidemic, even to generalize in Latin America would be a bit shaky, because I think even within Latin America the epidemic varies if you look from country to country. But certainly there's an epidemic of men having sex with men. That's a major driver in parts of Latin America as well as heterosexual transmission.
But the epidemic, I think in Latin America is certainly not on the scale that we see in sub-Saharan Africa. I think one of the challenges is getting better information on the epidemic in Latin America and the people I talk to agree with that. We don't have good information on the size of the epidemic, this is Latin America and the Caribbean, as well as the drivers.
So I think more work, on-going work, needs to take place on that front. But just take the point that we also support programs in Latin American through PEPFAR. Any U.S. global systems on AIDS is PEPFAR.
But the other aspect is the global fund, and there are number of -- there was a decision recently made at the last global fund board meeting that middle income countries, some middle income countries, especially in Latin American and the Caribbean would now be eligible for global fund grants. So that will be a major way for Latin American countries to access global resources for HIV that they can't generate in their own country.
QUESTION: And regarding the difference between developing countries and developed countries, what kind of numbers do you work with? Is this increasing or decreasing?
DR. KENYON: Well, I think it's hard to make a finite statement that it's going up or down in developing and up or down in developed. I mean, we saw the report just here from Washington, D.C. So we see that we have in our own backyard a major problem that's not going down. So I think developed countries have major epidemic concerns or should have major epidemic concerns, especially Eastern Europe, where the size of the epidemic pales in comparison to sub-Saharan Africa but the rate of increase is very alarming.
QUESTION: My name is John, John Monibah, from the College of Journalism at the University of Maryland. You said that you work with individual countries and especially when it comes to these people now have to come from the (inaudible) country. What information do you have on Liberia, where I come from? The second thing is, in Liberia I know there's an AIDS organization. Do you deal with them on the ground? Do you deal with people infected with AIDS or you just deal with countries?
DR. KENYON: Yes, that's -- I'll do the best I can to answer specific country information. I think Liberia recently completed a national survey because again that was part of the problem, they didn't know. Typically West Africa is run at lower prevalence levels than east, central, and southern Africa. I believe the prevalence was somewhere around 1.5 percent at a national level.
Liberia is, of course, being back on its feet and has restored peace and democracy is an important country for the United States to work with and support. Now that we have some evidence, some data, on the epidemic that helps us to help Liberia. Our total funding for Liberia is around at this point in time is around $950,000, relatively small compared to some of the other countries.
We have two programs, one through -- we have a defense collaboration between our military and Liberia's military because a lot of HIV, I wouldn't say is necessarily driven by the military, but they work as peacekeepers, they move around a lot, but they're also important models to the rest of society.
I saw a lot when I lived in Botswana. When a soldier came to the village, he's looked up to. He's got a uniform, he's got an education, he's, you know, people in society look up, so their behavior can be very much modeled by the rest of the community. So the defense group is working particularly on a prevention program with the Liberian military that's being integrated into existing training programs and the medical program, and so, like I alluded to earlier, they're building capacity into a program that previously wasn't really there.
So they're really getting off the ground. They're planning to within the military carry out a serial prevalence survey to see what is the extent of the problem within their own ranks and establishing a peer education program to empower some soldiers to support other soldiers as peer educators.
For the military it's mostly a prevention approach. That makes sense when you have prevalence of 1.5 percent that prevention would be find the drivers and work on those before it gets to a higher level. So care and treatment might be considerations in Liberia but not on the extent that they are in other parts of Africa. Prevention is probably the number one and probably number two and three focus that they ought to have. Also through USAID there's --
QUESTION: Is that a separate program?
DR. KENYON: -- yes, this is within Liberia, a $700,000 program, again mostly around the prevention like I talked about, the ABC approach, helping to empower youth to wait, working on partner reduction and fidelity, and condom distribution as part of this behavior change approach for prevention I was talking about. There also, you asked about engaging people living with HIV. We think that's extremely important.
In fact, a lot of the staff on our teams are people living with HIV. I constantly work with people, they understand the challenges that they face better than anyone else, are very important contributors and participants in implementation programs. So, and that seems to be an important aspect of the AID collaboration. And also they're working on a life skills program for youth, both in and out of school youths. The out of school youths who are more challenging to reach are at very high risk as you can imagine. And so rightly so that seems to be a priority for the Liberia team.
QUESTION: The recent survey, do you have any figures?
DR. KENYON: Sorry?
QUESTION: Any figures from the recent survey?
DR. KENYON: I don't but we can try and see if we can get you some.
QUESTION: Right, okay.
DR. KENYON: Yeah, I don't come armed with all the country information.
QUESTION: Thank you. My name is Talha Gibril. I'm from AsharqAl-awsat newspaper. I noticed that you did not say anything about North Africa. There are a lot of Africans actually crossing the desert into North Africa countries and try to emigrate to Europe, okay? And there are some reports from these countries that a lot of them also are unfortunate in that they have the virus of HIV. So if you can tell us something about the North Africa if you have got some information or program or something like that?
DR. KENYON: Thank you. You know, globally, if we look at North Africa it is a relatively small piece of the global epidemic but that doesn't mean it's not a problem. Just proportionately speaking like West Africa it's a smaller portion of the global epidemic and the Africa epidemic.
Mobility, wherever it occurs, is a risk factor for HIV. Mobile populations it doesn't matter, and I think that's a lot of the driver behind southern Africa is there's a lot of mobility for employment, for economic purposes that is actually very historical. So I can't give any comment specifically on that particular migration.
But I think mobility in general will be where you find HIV, where you should actually look for HIV. In fact when we do country surveys, one of the first groups we go after if we're looking for higher risk groups, would be mobile populations; the classic is of course the truck drivers who have to remain at borders for many days and purchase sex on the borders and of course that's very high risk and transmit it back to their households very often.
So that would also be something, I'm not sure if the truck traffic to North Africa because the desert is so, yeah, there's probably not too many roads through there, but I would not be surprised if any mobile group moving from west to north Africa is higher risk than the general population. That wouldn't surprise me at all. We can try, I don't know if we have more information -- we would know better the assistance package back at the office.
QUESTION: I'm Regina Dumba from Zimbabwe, and I see from the tables that you have here there's no numbers for Zimbabwe; and also what I want to say is before I came here in July I was involved with the (inaudible) society to do a proposal for the Global Fund, and one of the obstacles that we face when we were doing that proposal was the (inaudible) because the global -- the government of Zimbabwe had been denied of the global funds I think for the past (inaudible) and now (inaudible) civil society trying to access those funds, so there was a lot of animosity between government and the (inaudible).
And also one thing to say, there's a very thin line between HIV and AIDS at (inaudible). It's just (inaudible) like there was a time when we thought HIV and AIDS was an ethical issue only to realize that it's also social issue. So I don't know what you can say on the numbers of the people who are on the (inaudible) right now in Zimbabwe, but also looking at the migration of them going to Botswana and because I realize Botswana had a very good roll out plan (inaudible) so most people were migrating and finding their way in Botswana (inaudible). So I don't know what you can say about the (inaudible).
DR. KENYON: Yes, and actually I think there were several questions embedded in your thought. On the civil society participation, and we think that's immensely important to the global fund and we're concerned by their lack of acknowledgement to be at the table. They should be at the table along with government and Ambassador Dybul, the Global AIDS Coordinator, who serves on the board in the finance and auditing committee is very committed to ensuring that civil society is well represented on the country coordinating mechanism and has a recourse, an option, accessibility to proposals just as government should. Government should not be impeding the civil society's access to these resources.
Now, of course, the proposals do need to make sense and they need to be responsive to the epidemic but civil society plays an enormous role and we support that 100 percent. On the numbers, you know, Zimbabwe is, it's not one of our 15 focus countries but it is a country that receives substantial assistance through PEPFAR. In 2007 the amount was around $23.5 million and that's implemented in country through USAID and the Center for Disease Control, CDC, primarily.
Now one good thing is Zimbabwe's been one of the signs of success of the prevention program. Prevention programs have resulted in prevalent declining in Zimbabwe. You could argue it might be other factors as the economic issues might also be factors.
But I think some behavioral surveys that have been done in Zimbabwe, sequential behavioral surveys, we've seen the ABC outcome going on the direction that drives prevalence down so Zimbabwe's becoming a success. I would be reluctant to call it a success because you still have a long way to go and no one would be satisfied with leveling off at those prevalence figures but Zimbabwe is progressing on the prevention front.
QUESTION: (Inaudible) with some colleagues in the office that the rate of infection had actually decreased in Zimbabwe from about 23 percent to about 18 and they were like saying that's still too high but I think yes it's still too high but (inaudible) that the country is going through a crisis. But the follow up question is why isn't Zimbabwe in the list of your 15 focus areas?
DR. KENYON: Well, I think, I mean, looking forward it's probably -- there's no point to look back. I think if we look forward and when the President announced the next phase of PEPFAR there wasn't reference made to focus countries.
The focus countries again, that's half of the world's epidemic and that was designed to help to work with those countries to take services to scale, to take programs to scale, not these little pilot projects here and a pilot project there that are doing good things but not reaching a substantial portion of the population.
So the focus countries are taking it up to scale, and so we will be looking to, well, I mean, we have a partnership with Zimbabwe so we wouldn't be looking for a new partnership with Zimbabwe. We have one.
But one of the aspects of the next phase of PEPFAR is going to be having more up front discussions with governments as to what can the U.S. Government contribution do to compliment what the government is prepared to do, because we wish to see government step up to the plate and invest more in health when they can, trying to aspire to the Millennium Development Goals and trying to reach 15 percent of the national budget going to help. That's the global target.
And also are there policy issues that impede implementation. There's no point in having money in a country when we have policy obstacles that are in between those resources reaching to people with the right strategy. So those two discussions will be carried out with leadership and countries in the next phase of PEPFAR.
QUESTION: I'd just like to, you mentioned the drivers for southern Africa and you mentioned just one now. What other drivers are there for southern Africa? And you talked about just now affected that the (inaudible) it's not just medical, it's not just political, there are some other factors as well. Is this sort of psychological (inaudible) certain level of your social living where you're poor and crime is high and nothing is going right for you, you just don't care anymore. You don't care if you're going to contract HIV or anyone in your family. I just like to know, you know, discuss (inaudible).
DR. KENYON: Yes, that's a great point, and I think even talking in southern Africa can be an overgeneralization because countries are vastly different and within countries there are a lot of variations. My last assignment was Namibia. The northeastern corner was 43 percent. The northwestern corner was 9 percent and it was a seven or eight-hour drive between them. What's different? Well, that was the confluence of five countries and massive mobility; different culture, too. This was a more isolated area that just didn't have as much access to the outside world.
So it can be hard to overgeneralize about drivers, but I can speak to the data and what I know. Certainly the concurrency is the major driver, but there are a lot of issues behind that. Economic considerations that you've alluded to that create a certain sexual network, or social network. A sexual network comes out of a social network and so what creates a social network will drive the sexual behavior within that network.
So there are a lot of things that drive that social network, including seeking work and you know, historically southern Africa has been a very mobile area. If you go way back and look at maps, 1800 maps, there were gold mines in South Africa and Botswana was sending, you know, every country was -- so there's that heritage of mobility that is still in play.
Another driver that I think we don't talk enough about is alcohol, but again that's maybe alluding to some of the hopelessness that you referred to because it's a form of entertainment. It's also another addiction and it's something that also drives sexual behavior, and like I said, social networks and thereby sexual networks and we don't talk about that enough and I think in, and there is data in other parts of Africa as well, we did a study in Botswana and found it to be a major determinant of -- it wasn't just alcohol consumption, it was alcohol consumption and sexual behavior being linked with another.
Alcohol itself obviously wouldn't be a mode of transmission. I don't want to make that impression. I've already had that discussion with the breweries. So what are you talking about? And obviously it's a behavioral factor. There's the intergenerational sexual patterns. Young girls, women with older men, for lots of reasons; economic, status, peer pressure, lack of self esteem, not being equipped themselves with life skills to be able to say no, traditions that preceding them, culture.
So I think, I mean that's actually, if you look at the initial -- it's like if I had a set of dominoes that's kind of the first domino is when older men meet up with younger girls, that's when transmission basically begins. Then they, the girls move up into their generation and there's more back and forth from, you know, women to men and men to women.
If you look at the epidemic trends, girls in the group or women in the younger groups, are always higher and then men in the older groups are always higher and they catch up with one another in the mid 30s roughly. So that intergenerational, a transgenerational sexual patterns, tradition as you call it, is a big driver.
So mobility, alcohol, we've talked about gender inequities a little bit but again back to the lack of women's decision-making power when it comes to sexual behavior, that's huge. One could go on and on about drivers.
QUESTION: My name is Ablorh Odjida, from the Ghana Dot African group. There was a question about vaccine that you (inaudible) vaccines. How do you, PEPFAR as a group, (inaudible) been looking at the traditional area to see there could be a cure within the traditional medicine community. I say this because the traditional medicine in Africa is very, very profound in the sense that at one end you have a whole lot of charlatans and at the other end there's a real cure.
The problem of knowing what the real cure is, it is very secretive that whatever the cure is it's carried on from generation to generation, or passed on from one, you know, relative to the other and nowhere else. Has there been any interest in PEPFAR to look at this area to come forward with the knowledge that (inaudible)?
DR. KENYON: Well, sure, I think that interest long precedes PEPFAR. One of my first experiences with training traditional healers in Swaziland around HIV/AIDS, he actually approached us. He said we're worried about picking this up during the course of our traditional medicine and you know how cuts are made and they deal with blood, they deal with body fluids.
So you can go back to the beginning of the epidemic and healers have been trying to see -- I think we have to be careful with the use of the word "cure." Even with antiretroviral treatment we don't have a cure. We have something that can suppress the virus so that the immune system can recover but the virus will always, always be there.
So that wouldn't even be an aspiration I think that we could expect from traditional medicine. So there's been a lot of efforts over the years that actually the supports come from the countries. Uganda has a formal structure looking at this.
South Africa has a formal structure looking at this, and Zimbabwe with, you know, internationally recognized research institutions and I think they're still looking at it. You know, most of what you hear anecdotally is traditional medicines can help with some of the symptoms that, but we don't formally use those in the medical sector, but there's been more headway it seems in helping with some of the symptoms, the diarrhea symptoms, skin rash, putting on ointments and stuff people with HIV get a lot of rashes and so forth.
But in terms of actually affecting the virus itself and the immune system, there's been a lot of hopes raised that go way back before PEPFAR that just have not yet materialized into something that certainly would not even get close to -- we're not going to get a cure even with traditional, you know, I don't think anyone would aspire to that, but again, I think countries have been and will continue to look at that.
We ourselves, we work with institutions, our research is based on proposals that come in from research institutions, both domestically and internationally so they have to propose and it goes through our NIH, our National Institutes of Health, so that country would have to propose such research. It gets reviewed by a domestic and international panel to see if there's merit in supporting that.
But like I said, I think the countries themselves have been motivated to do that with some of their own resources.
QUESTION: And just to give you a brief on Zimbabwe on that, the traditional healers come together to come up with a plan, but like you say, you do not have the cure. All you have is something to treat the opportunistic infection like the rash, the diarrhea, and everything that comes with it. And then along the way there was a lot of fake medicine coming out.
Now people are not going to hospitals now, they are going to traditional healers, and they could not have consistent treatment because of a lot of issues in play and also there is also the issue of witchcraft, like you go to a traditional healer, they tell you no it's not even HIV and AIDS you've been, there's a lot of witchcraft in your family and then at that point the government has to put a halt to the whole thing of traditional healers and then ask people to go back to hospitals.
QUESTION: Yes, but I think this is something very, very different and I'm thinking of a very different approach. Rather than, you know, looking at the ceremony that surrounds this cure, the government interfacing with individual healers. You have a cure, come to us. I say I use this, yes I know (inaudible) cure. But hopefully if there is a cure we will all be happy and there's just no way of knowing that there will never be a cure, okay. So somewhere out there there is a cure. Who has it? Okay, so this is where the investigation I think should go.
So if the government interfaces with the traditional healer, forget the ceremony. What do you have? Herbs? Bring it. Let us test it. And if it works, fine. How do you reward such a person? And if you're going to reward that person how are you approaching it to bring forth the knowledge that he has for you to achieve your objective that you want.
DR. KENYON: I think traditional healers can play a very important role that goes beyond even the cure or treatment consideration. They have credibility with the community. So we really need to equip them with the proper knowledge. There's been a lot of misconceptions about modes of transmission such as, you know, having sex with a virgin. A lot of this -- these are very real issues -- a lot of misconceptions around transmission including, you know, that AIDS is a traditional disease so it's not transmitted through sex, it's transmitted through being cursed or people with witchcraft and so that's a disincentive to behavior change.
If you think I'm sick now because somebody hung a bush outside my door, it's that person gave me that disease, it's not because of what I did or somebody did to me sexually. It was because of that. So we really need to ensure that they're equipped with adequate information.
There are efforts under way in some countries -- I think it's in South Africa, I think it's in the Durban area -- of actually training traditional healers to carry out testing for the virus, because people go to them. They have the trust, and if they hear from a healer that they have HIV they will be convinced. They may have already heard that down the road at the clinic, but now they're going for "I'm not going to believe that. Maybe I'll go to the healer because he knows or she knows," and a lot of women, they know best.
So we would be doing the public a disservice if we didn't engage them effectively. But they need to find what they think their role is.
But I think we just have to manage our expectations when it comes to any cure or effective treatment. I think there may be room for the symptomatic, but that's up to the country to decide what's appropriate for it.
Thank you.
